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          <h1 class="post-title" itemprop="name headline">韩亮 《在你诊室跟我做——洗牙》听课笔记</h1>
        

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        <p>极周在线免费视频<br>口外研究生，后来做全科医生。<br>洗牙能拉近医患关系。每个中国人都洗牙，需要200万医生。<br>诊断流程图<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/01.png"><br>始于牙周，终于牙周维护。<br>宏观概念：用洁治器械去除龈上牙石，菌斑和色素，并抛光牙面同时应该将与龈上牙石相连的浅的龈下牙石一并清除。<br>适应症：是每一个牙周患者必须接受的最基本治疗，是牙周病预防和治疗最基本的手段之一，是开展其它全科治疗的基础，是长期口腔健康的保障。<br>原理：电能通过转换器转换为高频振动（2-4.5万赫兹），去除菌斑，色素和牙石。<br>作用机制：机械、冲洗、空穴、微声流作用<br>超声洁牙机工作类型：磁伸缩、压电式。<br>压电式：前后直线型运动，只能用工作尖侧面接触牙面。<br>磁伸缩：椭圆形，可用各个面接触牙面。<br>关键环节：工作头放置于牙冠切线位，侧缘轻接触牙面，转换角度。压电式尽量避免敲击牙齿。不同地方接触牙齿声音是不一样的。手的位置要不停变动。<br>技术要点<br>    目的：高效去除龈上牙石，菌斑，配合手工龈下刮治和根面平整。<br>    技术要点：<br>         ①始终保证工作头与牙冠切线位放置、侧缘轻接触牙面。<br>         ②叠瓦式进行龈上洁治和配合手工龈下刮治。<br>         ③尽可能直视下进行洁治和龈下刮治操作。<br>         ④用耳听，判断工作头是否处于良好工作状态。<br>             声音柔和、不刺耳，正确。<br>             声音刺耳、尖利声，错误。<br>注意事项：<br>    ①禁止将工作头的顶端停留在一点上振动，这样会损伤牙面。<br>    ②禁用于安装心脏起搏器者或者患有乙肝、结核等慢性传染病者。<br>    ③金属超声工作头禁用于钛种植体或瓷修复体。<br>    ④注意喷雾污染，洁治前使用抗菌漱口水。<br>操作流程<br>连接手柄：压电式，按特定方向插入，插入后不能转动。磁致伸缩可旋转。<br>调整水量：使水能连续。<br>调整功率：使水呈雾状。<br>医生体位<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/02.png"><br>医生操作范围：6区-12面（上下后牙，上下前牙，颊舌侧）<br>医生活动范围：8-9点-11-12点位。<br>患者姿势：抬头低头，左偏右偏。<br>8-9点位操作范围：右下颌颊侧，左下颌舌侧，右上颌颊侧，左上颌腭侧。<br>11-12点位操作范围：上前牙唇侧&amp;腭侧，右上颌腭侧，左上颌颊侧，下前牙唇侧&amp;舌侧，右下颌舌侧，左下颌颊侧。<br>第一步：右下后牙颊侧和左下后牙舌侧<br>1.患者头保持正中或偏右侧，低头洁治右下后牙颊侧。<br>2.低头偏向左侧，看到左下后牙舌侧。<br>第二步：右上后牙颊侧和左上后牙腭侧。<br>3.8-9点钟患者头仰，保持正中或略偏向右侧准备，洁治右上后牙颊侧。<br>4.8-9点钟患者仰头左偏，准备洁治左上后牙腭侧。<br>第三步：上前牙的唇侧和腭侧<br>5.医生12点位，患者头居中，仰头，洁治上前牙的唇侧、腭侧。<br>第四步：下前牙的唇腭侧<br>7.医生12点位，患者头居中，低头洁治，下前牙唇侧、舌侧。<br>第五步：上后牙、右腭侧，左颊侧。<br>医生12点位，患者头偏右，仰头，洁治左上后牙颊侧，右上后牙腭侧。<br>8.医生12点位，患者头偏右，仰头洁治左上后牙颊侧。<br>9.仰头右偏洁治右上后牙腭侧，从远中到近中。<br>第六步：下后牙右侧舌侧，左侧颊侧<br>10.医生12点位，患者头偏右，低头洁治右下后牙颊侧。<br>11.医生12点位，患者头偏右，低头洁治右下后牙舌侧。<br>（上下后牙也可以在8-9点位）<br>每个牙齿都要分为远中、中部、近中三个部分洁治。顺序是从远中到近中。<br>操作支点：有口外口内。<br>超声洁治的连接与调整：头是扁的为压电陶瓷，头是圆的是磁致伸缩。<br>力度：如羽毛般。<br>牙面接触：只能以侧面接触。<br>抛光<br>矽离子抛光主要抛牙釉质的色素，或者树脂充填后。<br>标准抛光是用抛光杯。<br>它是洁治后应进行的一项常规操作。<br>治疗目标：去除牙面上残留散在点状色素及肉眼难辨别的细小牙石，磨平牙面上细小的划痕，使牙面变得光滑舒适，延缓菌斑色素沉积。<br>时机和适应症：①首先牙龈炎症较轻或基本控制后；②且要在去除牙石、菌斑后进行；③它也是在洁治后，牙面需光滑处理必须进行的一项工作。<br>抛光技术要点：①安置好橡皮杯，调整好转速；②取少量抛光膏放于橡皮杯内，轻加压并低速旋转；③橡皮杯的薄边缘应达颈部牙面上，并深入龈缘下。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/03.png"><br>总结：①全面评估，以合理需求为导向，注意前后牙功率、水量、大小的调节；②医生的工作范围从8点钟-12点钟，顺时针依次完成整个区域。③保持轻松、良好坐姿，患者只需4动即可。<br>术后医嘱：教正确刷牙，方法，时间，次数。使用牙线；建议每半年或一年复诊一次。<br>放一个他们的公众号吧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/04.png"><br>接下来是实操<br>1.调整患者及自己的体位。上身成90°，上臂自然下垂，前臂与地面平行。<br>2.洗手，戴手套。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/05.png"><br>3.运动方式，侧面运动，接触侧面。正确的接触运动声音很小，否则声音很大。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/06.png"><br>4.操作顺序：从面向医生最近的位置（8-9点开始）。患者头部正中或偏向右侧。<br>第一区<br>头正中或偏向右侧。<br>右下后牙颊侧：47远中-44近中。每颗牙分远中、正中、近中三个部分，彼此有重叠。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/07.png"><br>左下后牙舌侧：头偏向右侧，37远中-34近中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/08.png"><br>这里貌似操作反了，或者是视频拍摄的问题？<br>第二区<br>右上后牙颊侧：头后仰，偏右或左，17远中-14近中。握持器械力量很轻，<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/09.png"><br>左上后牙腭侧：头后仰，偏做，在8-9点位。27远中-24近中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/10.png"><br>口镜的作用，反光，挡水。恶心的问题，把吸唾管放好。<br>第三区<br>医生进入12点体位，手臂自然下垂，别抬着。患者头回正。<br>上颌前牙唇侧。可放下口镜，用手牵拉，从23远中到13远中，工作尖与牙面0角度线接触。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/11.png"><br>上颌前牙腭侧。体位姿势不变，用口镜观察。从23远中到13远中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/12.png"><br>可以适当前倾，但最多15°。<br>如果用压电陶瓷，要不断变换手保证器械侧面接触牙面。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/13.png"><br>第四区<br>下前牙唇侧，头位不动，从33远中到43远中。<br>下前牙舌侧，头位不动，可直视或用口镜，直视可调整体位。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/14.png"><br>第五区<br>头后仰向右侧倾斜<br>左上后牙颊侧，27远中至24近中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/15.png"><br>不用使劲握持，靠其自身力量。<br>右上后牙腭侧，17远中至14近中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/16.png"><br>第六区：<br>头正中或略向右偏。<br>左下后牙颊侧，37远中至34近中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/17.png"><br>要注意患者的动作。<br>右下后牙舌侧，头向右倾斜。让患者动头并不会不适，反而保持一个姿势会不适。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/18.png"><br>注意支点位置。<br>细节：口镜牵拉口角最好用拉，不要用撬，碰到附着龈会疼的。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/19.png"><br>患者体位太高，就要抬臂低头。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0164-xy/20.png"></p>
<p><strong>操作总结：用工作尖侧面以接近0度接触牙面，每个牙面从远中到近中，分成三个部分，叠瓦式移动。羽状握持器械。不要刻意用力。操作顺序：8-9点位，右下后牙颊侧，左下后牙舌侧-&gt;右上后牙颊侧、左上后牙腭侧-&gt;12点位，上前牙唇、腭侧(腭侧可用口镜)-&gt;下前牙唇、舌侧-&gt;左下后牙颊侧、右下后牙舌侧。抛光杯抛光。</strong></p>
<p>提问：<br>矽离子抛光？<br>轻压抛光，重压打磨。硅橡胶+砂石。主要用来抛树脂，达不到抛光要求。橡皮轮较软，主要靠抛光膏。<br>喷砂？<br>切向或唇向去喷，但患者感受不好。喷砂是将表面粗糙的。<br>医患沟通？<br>与汽车保养做对比。<br>龈下牙石？<br>浅的，与龈上牙石相连可以去除，过深，过厚的，不能去除。急性，多发性，坏死性龈炎的，不主张马上做。菌斑性的炎症可以做。<br>儿童洁治？<br>釉质薄，敏感，恐惧。<br>抛光敏感？<br>用手指试一下，牙龈比手指更不敏感。</p>
<p>昨天在极周在线的公众号里看云南牙周显微大会的讲课视频直播，后来发现极周在线上有几个免费的视频，就看了。听了蛮不错的，临床上有洁治的试一下这个顺序。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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